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PERSISTENT DEPRESSIVE DISORDER (DYSTHMIA)
 


Prediction: Lasts For Years (10% per Yr Spontaneous Recovery)

      Occupational-Economic:
  • Work impairment due to chronic depressed mood
      Wisdom vs Irrationality: N/A
      Courage vs Negative Emotion:
  • Depressed mood
  • Low self-confidence, pessimism, loneliness and hypersensitivity to rejection
      Community vs Detachment: N/A
      Moderation vs Disinhibition: N/A
      Justice vs Antagonism: N/A
      Medical:
  • Chronic or disabling medical conditions increase risk of this disorder


SYNOPSIS

Dysthymia F34.1 - ICD10 Description, World Health Organization
A chronic depression of mood, lasting at least several years, which is not sufficiently severe, or in which individual episodes are not sufficiently prolonged, to justify a diagnosis of severe, moderate, or mild recurrent depressive disorder (F33.-).
Persistent Depressive Disorder (Dysthymia) - Diagnostic Criteria, American Psychiatric Association

This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. An individual diagnosed with persistent depressive disorder (dysthmia) needs to meet all of the following criteria:

  • Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years.
    Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

  • Presence, while depressed, of two (or more) of the following:

    • Poor appetite or overeating.

    • Insomnia or Hypersomnia.

    • Low energy or fatigue.

    • Low self-esteem.

    • Poor concentration or difficulty making decisions.

    • Feelings of hopelessness.

  • During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the above symptoms for more than 2 months at a time.

  • Criteria for a major depressive disorder may be continuously present for 2 years.

  • There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

  • The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

  • The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.
This common disorder is a chronic depression whose symptoms are less severe than those in major depressive disorder. Its depressive symptoms must be present most days over at least a 2-year period (1 year in children and adolescents). Major depressive disorder may precede this disorder, and major depressive episodes may occur during persistent depressive disorder. Individuals whose symptoms meet major depressive disorder criteria for 2 years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder.

Effective Therapies

Individuals with persistent depressive disorder (dysthmia) may respond to psychotherapy, pharmacotherapy, or a combination of both. The medications that are effective in treating major depressive disorder are also effective in persistent depressive disorder (dysthmia). These individuals require a longer treatment period, more psychotherapy sessions, and/or higher doses of antidepressant medication than do patients with acute forms of depression. Treatments effective for young adult dysthymic patients may not be as useful in elderly persistent depressive disorder (dysthmia) patients. Cognitive behavioral therapy (CBT), interpersonal therapy (IPT), and cognitive behavioral analysis system of psychotherapy (CBASP) are effective for the treatment of patients with this disorder. The rate of relapse/recurrence of symptoms has been shown to be reduced by long-term treatment with antidepressant medication and with long-term use of specific psychotherapies.

Ineffective Therapies

Vitamins, dietary supplements, and acupuncture are all ineffective for mood disorders.

Lack Of Social Skills During Persistent Depressive Disorder

There are social skills that are essential for healthy social functioning. During persistent depressive disorder, individuals lack the essential social skills of self-confidence, optimism, belonging, and sociability. These are the same social skills that are lacking in individuals with major depressive disorder, avoidant personality disorder and social anxiety disorder.

    Social Skills That Are Lacking During Persistent Depressive Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Self-Confidence Feeling inferior or shy Having a good opinion of one’s self and abilities; socially confident and out-going
    Optimism Pessimism or expecting the worst Having a positive outlook on life; expecting a good outcome; hopeful
    Belonging Fearing rejection by others Feeling liked and accepted by friends, and included in their group; not fearing rejection
    Sociability Social withdrawal Friendly; interested in social contacts and activities

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, community, moderation, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Persistent Depressive Disorder (Dysthmia): Negative Emotion
            Wisdom vs Irrationality: N/A
            Courage vs Negative Emotion:
      • Depressed mood
      • Low self-confidence, pessimism, loneliness and hypersensitivity to rejection
            Community vs Detachment: N/A
            Moderation vs Disinhibition: N/A
            Justice vs Antagonism: N/A

Prevalence

The U.S. 12-month prevalence is 0.5%. In adulthood, women are 2-3 times more likely to develop this disorder than men.

Course

This chronic disorder usually has an early and insidious onset in childhood or adolescence. In adults, up to 75% of individuals with this disorder will develop major depressive disorder within 5 years. The spontaneous recovery rate for this disorder is approximately 10% per year. This recovery rate is significantly better with active treatment. Personality disorders and substance use disorders are more likely to be associated with this disorder if persistent depressive disorder starts before age 21.

Familial Pattern

Persistent depressive disorder is more common in the first-degree biological relatives of individuals with this disorder, and those with major depressive disorder.

Complications

By definition, there must clinically significant distress or impairment in social, occupational, or other important functioning as result of this depression. In childhood, this disorder is often associated with impaired school performance and poor social interaction. Children and adolescents with this disorder are usually irritable and cranky as well as depressed. They have low self-esteem, poor social skills, and are pessimistic.

Comorbidity

In adults, this disorder is associated with an increased risk of having major depressive disorder, anxiety disorders, substance use disorders, and personality disorders (i.e., avoidant, dependent, obsessive-compulsive, borderline, histrionic, narcissistic and antisocial).

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder. Sleep EEG abnormalities are evident in 25%-50% of adults with this disorder. These are the same EEG sleep abnormalities that are found in major depressive disorder (e.g., reduced rapid eye movement [REM] latency, increased REM density, reduced slow-wave sleep, impaired sleep continuity). Dexamethasone nonsuppression (which often occurs in major depressive disorder) is not common in persistent depressive disorder (unless it co-exists with major depressive disorder).

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